In health spending, middle-income countries face a priorities ditch, not a financing ditch – but that still merits aid

After a successful replenishment earlier this year, the board of Gavi, the Vaccine Alliance, is thinking through how to maximize the impact of the money it has raised. One hot issue is graduation from Gavi support. Currently, the Alliance uses an income cutoff loosely based on eligibility for IDA — soft loans from the World Bank. Other aid agencies, including the Global Fund to Fight AIDS, Tuberculosis and Malaria, also use World Bank income classifications as an important part of their eligibility and graduation systems.

Within the eligibility and graduation debates, a major touchstone is whether health aid recipients, as they get richer and graduate, are going to pick up essential health services currently funded by aid such as immunizations or antiretrovirals. And, if not, why not and what should donors do about it?